BY PAUL H. DWORKIN
The recent publication of an article, “Evidence-Informed Milestones for Developmental Surveillance Tools,” in the journal, Pediatrics, has attracted considerable attention from pediatricians, early care and education providers, and parents. I am hopeful that the interest in the article reflects increasing recognition of the importance of developmental promotion and the early detection of children for whom there are developmental concerns.
The Centers for Disease Control and Prevention’s (CDC) Learn the Signs. Act Early. program funded the American Academy of Pediatrics (AAP) to convene a group of eight experts in child development from diverse fields to revise its developmental surveillance checklists. Their research resulted in the replacement of a number of CDC milestones (41%) and one-third of retained milestones were transferred to different, mostly older, ages. The report also identified gaps in developmental data, especially for social-emotional and cognitive milestones.
This article is noteworthy for a number of reasons:
1. This is the next logical extension of the CDC’s Learn the Signs. Act Early. program. The campaign’s primary focus has expanded over the years from the early detection of autism to include children with a broad range of developmental concerns. It has also evolved to explicitly focus on the importance of monitoring children’s development and the critical imperative of parent engagement and eliciting parents’ opinions and concerns. By improving the accuracy of the ages at which milestones are listed, the revised checklists can better support developmental monitoring and early detection.
2. The article accurately and clearly describes the integrated process of developmental surveillance and screening as best practice for developmental monitoring and early detection. This is not surprising, given the evolution of AAP policy statements and clinical guidelines, but the authors take great care in providing an accurate description of the process of early detection. Despite the approach being advocated by the AAP for a number of years, misperceptions continue to be promoted in the literature, such as debating the merits of surveillance vs. screening, pitting different components of a single process as alternative approaches to early detection. The authors’ emphasis on the comprehensive, integrated approach of surveillance and screening is much appreciated.
3. The actual intent of the article, to select milestones for surveillance typically achieved by 75% of the population, makes complete sense, as those tasks accomplished by 50% of children at a given age are not really very helpful in identifying those at risk for delay since, as noted by the authors, half of children are not expected to have achieved them and, as a result, may inadvertently encourage a “wait and see” approach. While the listing of milestones at ages by which the majority of children are expected to display competence is much more helpful in identifying children who may be demonstrating delay, the authors refrain from overstating the significance of findings and encourage them to be considered in the context of the child’s overall progress and family circumstances and suggest that concerns may be addressed by administering a screening test.
Our affiliates across the Help Me Grow National Affiliate Network have shared a number of different conversations on the article, including agreements and disagreements on the implications of changes to the milestone checklists and a variety of expressed concerns. For example, some worry that the movement of milestones to older ages may reflect a lessening of expectations for children’s developmental progress. Some have even suggested that the change in ages for speech and language milestones are likely a result of mask mandates with the COVID-19 pandemic and the inability of infants, toddlers, and young children to see the mouth movements and facial expressions of adults. Yet the studies upon which the expert panel revised the ages for different milestones clearly preceded the pandemic by years to decades. Furthermore, as previously noted, the shift of ages at which children achieve various milestones is simply a reflection of the intent to more clearly identify children who are lagging behind the majority of their peers and to encourage a closer look at children, through such methods as screening, when they are not meeting age expectations.
For those who understand the intent and purposes of this revision, the new CDC developmental checklists should be a welcome addition to our developmental monitoring and early detection strategies. We should view these tools as strengthening our capacity to engage families in effective developmental promotion and early detection, recognizing the benefits of embedding such activities within a system that ensures the capacity to refer and link children and their families to appropriate and desirable community-based programs and services. Also, we are once again reminded of the strong synergy between the CDC’s Learn the Signs. Act Early. program and the Help Me Grow Model.
Paul H. Dworkin, MD is executive vice president for community child health at Connecticut Children’s, director of Connecticut Children’s Office for Community Child Health and founding director of the Help Me Grow National Center. Dr. Dworkin is also a professor of pediatrics at UConn School of Medicine.
The HMG National Center has teamed up with the Learn the Signs. Act Early. Ambassador program at AUCD and HMG Connecticut to develop a list of resources to help affiliates understand, talk about, and utilize the new guidelines.